【摘要】 目的分析新型冠状病毒肺炎病历书写质量情况及其原因,并探讨对策。方法抽取某院2020年1月21日-2020年2月13日76份确诊和待排的新型冠状病毒肺炎患者出院归档病案,分析书写质量缺陷。结果 76份病案中检查出质量缺陷频次144次,其中流行病学史记录缺陷占23.61%(34/144)、主诉缺陷占16.67%(24/144)、病程记录缺乏部分诊断或鉴别诊断依据占5.56%(8/144)。结论针对新冠肺炎病历书写存在的缺陷,应加强病历书写培训、质控管理和信息化建设,提高病案质量,为总结新型冠状病毒肺炎的流行病学特点和疾病诊疗情况提供真实可靠的原始资料。更多还原

【Abstract】 Objective To investigate the writing quality of COVID-19 medical records, summarize the causes and discuss Countermeasures. Methods Retrieving 76 medical records of confirmed and pending patients infected by SARS-CoV-2 from January 21, 2020 to February 13, 2020, analyzed the deficiency in writing quality. Results 144 quality defects of 76 medical recordswere found, of which 23.61%(34/144) were the defects of epidemiological history, 16.67%(24/144) were the defects of main complaint, and 5.56%(8/144) were partial deficiencies of diagnosis or differential diagnosis basis in medical records. Conclusion Aiming at defects in writing quality of COVID-19 medical records, the medical institution should strengthen medical record writing training, quality control management, and informationizationconstruction, improve the quality of medical record. Thusthe medical records can provide reliable source material for understanding the epidemiological and developing features of COVID-19.更多还原